Airway Management of the Right Anterior Segmentectomy through Uniportal videoassisted thoracoscopic surgery (VATS) after left pneumonectomy by an adapted double-lumen endobronchial tube (DLT): A case report

- Airway Management of the Right Anterior Segmentectomy through Uniportal video- assisted thoracoscopic surgery (VATS) after left pneumonectomy by an adapted.
- Case presentation: A 48-year-old woman who had left pneumonectomy 2 years ago was scheduled to have the right anterior segmentectomy through uniportal video-assisted thoracoscopy (VATS).
- And the upper lobe can be isolated from the ventilation in the middle and lower lobes when the bronchial cuff ’ s inflated.
- The perioperative period was uneventful and the pathological diagnosis was adenocarcinoma..
- Conclusion: Lung cancer radical resection was discouraged after previous contralateral pneumonectomy partly due to the challenging ventilation and isolation.
- With this new DLT adapting and intubation technique showed in this case, the challenging ventilation and isolation that deter the implementation of the operation mentioned above could be solved..
- Double-lumen endobronchial tube (DLT) has been widely used in thoracic operations to acquire better surgical fields, and the left-sided DLTs are preferred over the right-sided DLTs, because of easier intub- ation, positioning and effective bilateral suctioning.
- Bronchial blockers (BB) are recommended in selective lobe blockade [3], however, BB is not omnipotent in selective lobe block- ade, as in this case, selective right upper lobe blockade en- tails the balloon to be placed in the right upper lobe bronchus, however, the short right upper lobe bronchus and the angle of the right main bronchus and right upper lobe bronchus would make the placement even more diffi- cult.
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- portant figures in the arterial blood gas test were showed as follows: pH 7.44, PaCO 2 37 mmHg, PaO 2 84 mmHg, SaO 2 97.7%.
- Routine monitoring was applied and the first data were recorded as follows: body temperature 36.7 °C, blood pressure 123/70 mmHg, heart rate 86/min and Sp0 2 98% when the patient was placed in a supine pos- ition in the operation room.
- After the insertion of an 18-gauge intravenous cannula and the right internal jugular vein catheter, intravenous induction was carried out with an injection of midazolam 0.03 mg/kg, sufenta- nil 0.6 μg/kg, propofol 1 mg/kg, and rocuronium 0.8 mg/.
- Intubation preparation: the patient was scheduled to have the right anterior segmentectomy through VATS after the left pneumonectomy, which entailed us to make a good balance between ventilation and collapse on the right lung only, to make good use of ventilation in the lower and middle lobes, and to produce an effect- ive collapse in the upper lobar.
- But it ’ s our first time to insert the left-sided DLT to the right for the right lung surgery.
- 1, the mediastinum has shifted to the left, the intub- ation should be gentle and carried out by an experienced anesthesiologist in case of any possible injury or even perforation to the former carina.
- After induction, we performed a FOB (3.0 mm diameter) guided endobron- chial intubation with the bronchial cuff into the right bronchus intermedius, and the tracheal cuff ’ s orifice up against the upper bronchial port (Fig.
- 3), in this way, the ventilation of the dependent right middle and lower lobes and the collapse of the upper lobar were guaran- teed (Fig.
- 4), thus an appropriate balance between surgi- cal field and oxygenation was achieved, and the blood and sputum from the upper lobe bronchial port can be sucked out.
- In the meantime, end tidal CO 2 and arterial blood gas analysis were recorded to adjust ventilation.
- The lung recruitment, air leak test and sputum suction went well throughout the operation and the surgery was com- pleted as planned.
- The patient recovered well after the surgery, so she was extubated in the operation room and sent to the postanesthesia care unit (PACU) for transition, where a routine oxygen supplementation was applied.
- Oxygenation, ventilation, and circulation were all strictly monitored and no adverse events were recorded in the PACU.
- It is a case of right lung surgery with previous left pneu- monectomy, which entails the resection to be least impair- ment to the respiratory function and least trauma as well..
- Uniportal VATS right anterior segmentectomy should be the optimal choice because of its complete removal of the tumor while maximally functional lung kept, and smallest intercostal incision left..
- First, a single-lumen tracheal tube (SLT) could be intubated into the right bronchus intermedius, this could make use of the ventilation in the middle and lower lobes, yet it also would lead to the upper lobar inflation, unless a detachment of the SLT with the cuff deflated and the ventilator was made before the establishment of pneumothorax.
- Besides, the blood and sputum from the.
- 4 The moment when pneumothorax completed, collapsed upper lobe and ventilated middle and lower lobes.
- chance, BB were suitably placed, it would have a great probability of being dispositioned given the thought of the short right upper lobe bronchus and the surgical intervention.
- First, we have to make sure the bronchial cuff is intubated into the bronchus interme- dius, and it can protect the middle and lower lobes from the upper lobe contamination when inflated, and the bronchial orifice should be above the middle lobe bron- chial port to guarantee the ventilation in the middle and lower lobes.
- But the length of bronchus intermedius var- ies, and that length was only about 15 mm in this woman while the length of bronchial cuff and the tip in- cluded was about 30 mm, so we cut off the tip (about 10 mm without damage to the cuff ) and made it clean and smooth without any possible damage to the human body.
- Still, our approach has some limitations too, the bronchial cuff of this modified DLT was meant to be po- sitioned in the bronchus intermedius, however, the shorter, the easier to be dispositioned.
- also, skilled adapt- ing and intubation technique, and the recognition of the bronchial anatomy are needed..
- But putting the DLT in the expected position doesn ’ t guarantee a safe oxygenation, considering the middle and lower lobes only for ventilation.
- All contributors for this study are those included in the authors..
- All data used in this report are available from the corresponding author on reasonable request..
- GY and DRW contributed equally to the drafting and revision of the manuscript, LX revised the manuscript, SJ collected, analyzed and interpreted the patient data, reviewed the literature and revised the manuscript.
- Written informed consent for the publication of this case report was obtained from the patient.
- A copy of the written consent is available for review by the Editor of this journal..
- Misplacement of left-sided double-lumen tubes into the right mainstem bronchus:

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